This morning, we will hear Rosemary Dodds. The Committee will have questions to put to her. We will then have a short private break to sort out questions to the Department. In that way, we shall not eat into the time of the National Childbirth Trust.
I thank you, Rosemary, on behalf of the Committee for coming before us this morning. If you are comfortable and ready to go, it will be helpful for the record if you tell us your name and position.
Good morning, Ms Dodds. You welcomed the proposal for a health in pregnancy grant, but also pointed to the need for continuing advice. Will you expand on your belief that the one-off payment will make a difference? What other measures do you consider necessary to improve on that?
Rosemary Dodds: The important thing is the intention of the payment. Originally, there was a lot of discussion about impact on birth weight and prematurity, but the intention of the payment has not been made clear. In order to answer the question about what the impact would be, we need to know the intention of the grant. If the impact is desired on birth weight and on prematurity, my understanding is that even 25 weeks is too late, from the evidence base, to have much impact. If the intention is to support pregnant women and to support new families—their health in general but also in a wider sense—that needs to be measured differently.
A contribution of £190 I am sure would be welcome because it is a time, as I have pointed out in the evidence, when families are particularly under stress and low-income families obviously are harder hit. The stress of being in debt or having a very low income is an additional factor in pregnancy-related disorders.
Are you effectively saying that you think the reasons that have been given for this grant are the wrong ones and, therefore, perhaps we are having the wrong debate?
Rosemary Dodds: I am not clear what the reasons are because my understanding originally was that the emphasis was to improve health and to improve diet in particular, with a view to reducing the risk of prematurity and improving birth weight in this country and, therefore, to give children a better start in the long term.
There is good reason to think that improving women’s diet at the pre-conception stage may have that impact but improving diet later in pregnancy is likely to have much less impact. Therefore, I would like to be clear, and I would like the Government to be clear, what the intention of the payment is because then it will be possible to assess the impact. Does that answer what you were asking?
Yes, I think it does and I think it is quite revealing. There has been a lot of criticism. You generally support the measure, although, as I think is clear, you support it perhaps not for some of the reasons that have been given for bringing it in. You are also aware that there is a lot of criticism about it. A lot of organisations and experts have said that they do not think that it is a good idea. In fact, the King’s Fund has dismissed it as, I quote, “silly”.
Because you think it is a good idea, albeit for different reasons from the ones that have been given for bringing it in, how do you think it could be changed? What other provisions do you think could be introduced or alternatives brought in to make it actually deliver and succeed in the way you that you would clearly wish it to be?
Rosemary Dodds: One of the things that would help would be to pay it earlier in pregnancy, from as early as possible, from 10 or 12 weeks, when women first attend for antenatal care. It should be possible to do that even if women attend later. They can start later and receive the same amount of money. I think the logistical problems could be overcome. It would then have the advantage of particularly supporting the women whose babies are born at 25 weeks. They are not going to benefit at all if the grant does not start until after 25 weeks.
The other thing that could have a potential impact on women’s health in pregnancy and their children’s future health would be to increase the healthy start payments which have been stuck at £2.80 since they were introduced. That is the same sort of level as they were previously under the milk tokens scheme.
Healthy start can commence at 10 weeks and continue throughout the pregnancy up to the age of four. That may also have an impact on the future pregnancies of a woman who is in a poor nutritional state when she starts her first pregnancy. It is a way of reaching the pre-conception stage for subsequent pregnancies and it also goes to all women under 18 who are pregnant, who are at a particular nutritional disadvantage.
Clearly healthy start is conditional and therefore is spent on exactly what it is devised to achieve. Do you think therefore that this new payment to women, whenever it is—you have clearly stated that, ideally, it would be earlier—should also have some conditionality to ensure that it is spent on something relevant to assisting diet, baby clothes or whatever? Do you think that there should be some conditionality?
Rosemary Dodds: In the same way that child benefit is not conditional on spending even that money on the child itself, there are advantages in enabling women to make their own decisions about how to spend the pregnancy grant. It may be that if they are in debt, the greatest advantage to them would be to pay off their debts and then reduce their ongoing interest payments, and then they will have more money available to spend on food. So I do not think that conditionality would overcome all the problems.
But again, presumably you then have to be clear what this payment is actually for, in the light of why it is being given. If it is supposed to be about diet, which has been one of the suggestions, and is going to be spent on debt repayments, that is not going to achieve anything in terms of diet. We must be clear on that.
Rosemary Dodds: As I say, it could have an impact on diet—if it means that women are spending less on exorbitant interest payments, they will have more of their household income to spend on diet. I think it is important to be clear about the intent in order to evaluate the impact, because I think that the Government want to be evidence-based and you cannot be evidence-based unless you have a reason for doing things.
One-off payments at some point during early pregnancy? Does the evidence from those examples support what Ministers have said, in terms of the way they expect the money to be used by pregnant woman, and what they anticipate the benefits will be?
It seems to me that a lot of the benefits we are talking about of this payment are theoretical, and I am not sure I have seen a lot of evidence to demonstrate that the grant will do what Ministers claim it will do.
Rosemary Dodds: No, but there is a lot of support for the redistribution towards families. Obviously there are many, many reasons for that, and the health of children in the very early stages—prior to conception and in the first few months—does have a long-term impact on their future health, in terms of their complete lifespan health. So there are some logical reasons to think that improving health, particularly among the poorest people, will have a future benefit. What you are saying is one reason why we think it is important to evaluate the impact of this and to commission research studies—we said the same at the launch of healthy start—to look at what happens to the grant and what impact it has.
It seems that you are looking at this in terms of poverty alleviation. If that is what you think this is about, then surely there should be a discussion about the right ways of helping poor, pregnant women. What we have here is actually a one-off payment to all pregnant women. Do you think it is fair to criticise it on the basis that it is not targeted?
Rosemary Dodds: I think that in order to reach all pregnant women who are in need, a universal benefit has a lot of advantages in itself, but there are advantages in supporting all women who are pregnant, whatever their income, because of the redistribution impact that I mentioned earlier and because this method of payment reaches many more of the poorest women. Universal benefits are well known to be administratively easier, both for those who are giving the money out and also for claimants, so that they are always clear that they are entitled and almost always apply. There is a very high take-up rate and therefore it is a very effective way of reaching people. As I mentioned in my submission, the End Child Poverty Coalition is very supportive of this move to increase universal benefits.
I wonder, Rosemary, if you are aware that the three European countries we are aware of that pay similar one-off grants like this all pay them at about the same time that we are proposing to pay this one? France, Finland and Belgium?
Can I ask if women will be informed enough to use this money in such a way that their own nutrition helps the foetal development? There are certain aspects of foetal nutrition, particularly, for example, in the laying down of the initial calcium for bones and teeth, where certain foods are very relevant. Are we satisfied that there is enough information out there so that when women get this money they really do have the knowledge and perhaps even the motivation to spend it on the right things that are actually going to help foetal health and the long-term health of the child?
Rosemary Dodds: No, I think you raise a very important point and as I have pointed out, health professional bodies have in general said that they do not have sufficient training on nutrition to provide individualised dietary advice to women. It is no good suggesting that women eat a lot more high-value foods if their income is not going to cover it, for instance. It is not only calcium and vitamin D, for instance, that are important, but also oily fish. There is a lot of confusion about oily fish yet there is good evidence that it can have an impact on the future health of the child. That is one reason why we mentioned improved training, particularly for midwives and GPs who have said they really do not have enough nutrition knowledge.
I am pleased to hear that, but I have to say, Chairman—I did study nutrition to an advanced level myself—I do wonder. If we take, for example, the battle Jamie Oliver had with the Turkey Twizzlers, just getting mums, particularly mums who were probably in areas where they most needed information and expertise on why to eat a balanced diet, to understand why fruit and vegetables are an important component of diet. I worry that socially, there is still lack of acceptance of the need to eat a proper, balanced diet; even if Marks and Spencer cut out all their salt and all these sorts of things happen, I worry that the people who would benefit most will not do so, because they either do not know, or equally are not going to use it because of lack of motivation to do so anyway.
No, I agree, but in terms of this particular grant, are you satisfied that the information exercise for the mothers will go hand in hand with the handing over of the money? Because if it does not—let us put to one side extreme cases such as women who, when pregnant, actually decide not to give up cigarettes or alcohol consumption; there will also be a small group of women who are drug dependent—one has to look at these groups and say, how are you going to ensure foetal health through additional resources?
Rosemary Dodds: That is why it needs to go hand in hand with advice from their health professional, which we are hoping will be improved through better training, and there are people who are willing and able to do that. Also, the NICE maternal and child nutrition programme development group is about to come out with its recommendations for reaching the most disadvantaged women with information on improvements in diet. We need to find the mechanisms to make that work.
I am grateful to Rosemary Dodds for making such a clear exposition of the challenges that we face in trying to make something intended to be a good, actually work. As best as we can understand, the genesis for this was when the Prime Minister was Chancellor and first announced the then extension of child benefit into the last months of pregnancy. He said that it was on the basis that nutrition is most important
“in the last months of pregnancy”.—[Official Report, 6 December 2006; Vol. 454, c. 308.]
Has the National Childbirth Trust, as one of the greatest practitioners and organisations in the field in the country, been consulted on that? Have you seen the evidence that supported it? Is it something with which you find yourself in total accord?
Rosemary Dodds: No, I cannot say that we were consulted. My reading of the evidence is that it is pre-conception and very early pregnancy nutrition that is most important. That is not to say that women who are sick and do not manage to eat very much at all will not have babies that are often just as healthy, so it depends on the functioning of the placenta, and that is influenced by many other factors. Diet is one factor, but definitely the time around conception is most important.
I am grateful for that. It will no doubt lead us to some interesting discussions during our deliberations in the coming weeks. At the outset of your remarks, you made clear that it is difficult to make judgments on the area until one is absolutely clear what the intention is. I think we are all agreed that it would be helpful when the Minister appears after you to try to gain some clarification from him. If the intention is to tackle birth weight and prematurity, that is one set of circumstances whereas if it is just for the general support of the mother and the family that is another set of circumstances.
On Tuesday we had the Which? representatives in front of us, and they indicated that they are willing to supply written evidence, as a result of our questioning, which might impact on what behaviour, influences and evidence can be found to make sure that the proposal will work. In your experience, what tends to influence the behaviour and choices of pregnant women? Particularly, as you say, at the conception stage and the early days of pregnancy, in the first three months when often they have not told many people—which is normal practice. What influences them to make the right choices? At the extreme level, cigarettes and alcohol are given up, but also, more positively, if this is to deliver, what influences their choice on nutritional improvement?
Rosemary Dodds: I have to say that the most important thing is education. Education in schools is one of the best ways of reaching people. We are aware, from research on encouraging women to take folic acid prior to conception and for the first 12 weeks, that it is the women who are most well educated, most likely to look at websites and read magazines who are most aware of that information. We need to put more emphasis on providing girls in particular, but girls and boys in general, with nutrition education in schools and encouragement to implement those nutrition messages by explaining the impact on the future health of themselves and their children.
I am grateful. I was interested in the Minister’s question about the three European countries. The other evidence we have is from Australia, where some people have, rather brutally, called their one-off payment the “plasma payment” because of the tendency—which is, I expect, anecdotal—of a number of pregnant mothers to go off and buy plasma screens rather than the necessary improved food. I am therefore anxious for us to understand, from your point of view, and with your experience and the great contact you have with pregnant mothers, with what evidence you would hope to show that this initiative would bring about the intended behavioural changes, to encourage women to make the right choices? Let us say that the cost is £80 million at the moment. If you were given a cheque for that amount, is this the way you would use it to improve maternal and foetal health?
Rosemary Dodds: The latter question I will come back to. In terms of improving awareness of the importance, I am likely to get into philosophy if I am not careful, because the importance of children in society and of the parenting role needs to be bolstered in order to encourage women to take their health and the health of their children seriously. At the moment, parenting is seen as an optional add-on for many people, and not something that is an important part of their lives. Work is the most important thing; parenting is sometimes denigrated and not sufficiently valued as an important part of the future society. That involves not only health, but how much time you spend with your children and how you bring them up. In order to encourage women in particular to improve their diet to maintain their health and the health of their children, I would like to see parenting and child rearing more valued in society.
There is quite clear evidence, however, that less well-off people—and less well-off women in particular—spend a higher proportion of any extra resources they have on their children.
I wonder what you think the Government might do more positively about the biggest single problem with foetal damage in pregnancy, which is from alcohol—particularly that consumed just prior to conception and during the early stages of pregnancy. As I understand it, foetal alcohol damage is far and away the most significant factor affecting babies before birth, causing greater damage than all the other factors put together. Have you got a message for Government, as to what they might do to improve the health of babies before they are born?
Rosemary Dodds: I do not see that that is the immediate topic in relation to the health and pregnancy grant. Smoking, alcohol and illegal drugs all have an impact on the health of babies before they are born and prior to conception. Obviously, some of those babies will not survive because of the substances that their mother is ingesting.
If I can interrupt, I understand that alcohol is overwhelmingly more significant than the other factors. It causes serious physical damage and mental incapacity later on.
Rosemary Dodds: I am aware of that concern, but I am not sure that the evidence is sufficiently robust. Many more women are smoking and we do not know the impact of very poor diets. Alcohol consumption is one of the factors, but I do not think that the correlations are as strong as you suggest. Yes, there is more that could be done to inform young women, in particular, of the dangers of drinking excessive amounts of alcohol, but so many of those women are also smoking—they are not considering that their health, or their baby’s health, is damaged by those behaviours.
I want to pick up on what Mr. Bradshaw said about the income being spent on the children, which is obviously important. There is evidence that women themselves go without food in order to give their children—and even their partners—the best, which adds to what I said about women not feeling that their own health is sufficiently important.
Miss Dodds, we have sadly come to the end of our fixed session with you, but on behalf of the Committee I thank you very much for coming before us this morning and for answering our questions so frankly and with such interest.
I am afraid that we have to clear the public gallery, as the Committee has to go into private session to prepare for the next questions for the Department, so I must require the public to leave.
We now move into the second question session with the Minister and his team. I am not going to allow the Minister to question himself as a member of the Committee, but he can certainly answer the Committee’s questions. Would you like to introduce your team, Mr. Bradshaw?
Ben Bradshaw: On my far left is Giles Wilmore, head of system management and regulation in the Department of Health; on my immediate left is Jonathan Athow, head of work incentives and the poverty agenda with the Treasury; on my far right is Nick Clarke, head of health and social care regulation in the Department of Health; and on my immediate right is Jonathan Stopes-Roe, head of strategy and legislation for health protection in the Department of Health.
We are all delighted to be involved in this new process and to have the chance to take evidence before we debate the Bill on a line-by-line basis. To open, it will, I hope, be helpful all round to establish what intent and motive lies behind amalgamation of the three bodies—the Healthcare Commission, the Commission for Social Care Inspection and the Mental Health Act Commission—to form the new Care Quality Commission, given that some of those bodies were recently formed and have not had the chance to bed down. We are just getting to the point at which they were demonstrating their experience and added value, and we have the opportunity to give them new powers, so what has persuaded you to establish a new commission at this stage? Has the measure come too late or too early?
Ben Bradshaw: There are two basic reasons. The first was articulated well by the Local Government Association when it gave evidence on Tuesday. Increasingly, on the ground, service users and members of the public do not interpret the bodies as unseamless, but services are increasingly delivered in an integrated way. Other political parties and stakeholders have for some time called for integration. We accept that change such as this is never easy; it will always cause an element of disruption. However, the reasons for the intent and the timing of the measure are that we have a legislative opportunity, there is increased integration on the ground and the Government are committed to reducing the number of public regulators to streamline and save costs, which I imagine most people here would support.
Are you satisfied that the provisions as they are currently laid out are in what we all accept is a framework or something of a portmanteau Bill? A lot of the devil will be in the detail. We now have some regulations to work with, which is welcome. Are you satisfied that there is not, through this disruption, a danger that things will fall through the cracks and that we might lose some things—a situation that might otherwise have been avoided?
Ben Bradshaw: I accept the fact that we have to manage this process very carefully. I also accept the evidence that was given by the LGA witness who said that whenever there is a transition like this, there are problems. However, he went on to say that those problems are easily outweighed by the benefits. We have to manage the process very carefully. We have been working at the highest level with the three organisations involved to try to address their concerns and to ensure that the transition is managed well, and that they continue to fulfil their responsibilities while we get a shadow Care Quality Commission up and running.
We hope that some favour may shine upon the transitional arrangements that we shall propose in amendments during the course of our deliberations. That would also include giving the same emphasis to social care as to health care.
Ben Bradshaw: I do not think that we need to worry too much about that given the fact that the social care section will be the bigger part of the new regulatory body. As we made clear on Second Reading, we are very sensitive to the concerns of the CSCI. We have addressed the concerns and we will continue to do so as we scrutinise the Bill.
Ben Bradshaw: I was as surprised as you were. In none of the meetings that I or the Secretary of State have had with Sir Ian Kennedy, going back more than six months, did he ever expressed those concerns either in the content or the tone in which they were articulated. I was also slightly concerned to read them in the press before evidence was given to this Committee. However, during the Sitting, we usefully teased out the position of the three regulators, including the Healthcare Commission. You may recall that when I asked Sir Ian, he said that since he wrote the Bristol report some years ago, it was his position that bringing together health care and social care is desirable. He said that the citizenry do not know and care less under what system they are being looked after. They want it to be seamless and well organised, so the principle is right. His concern seemed to be about the timing, and we have already had a brief discussion about that. In some senses, the timing is never attractive to someone who is already in charge of a regulatory body that is doing a very good job. It is not natural to welcome that level of disruption and also the abolition of your very good organisation.
You mentioned that your Department has been in discussion at the very highest level with the three existing inspectors. We heard from Lord Patel, Chair of the Mental Health Act Commission, about the importance of regular inspections and the expertise of the team of people who carry out the inspections. In his evidence to us, he seemed to be content,
“as long as those are retained and strengthened, we would support the Bill.”——[Official Report, Health and Social Care Public Bill Committee, 8 January 2008; c. 6.]
Given the fact that he said that to the Committee, can we accept that he has not had that reassurance from your Department’s in its discussions with him?
Ben Bradshaw: We have certainly given him that reassurance. I cannot quote verbatim the assurances that were given on Second Reading. The powers that his organisation have at the moment will be strengthened under the new Care Quality Commission. We do not think that it is for us to dictate to the new commission at this stage, saying that it should regularly visit particular organisations or institutions. There will always be a need to strike a balance between how much we prescribe here during the passage of this Bill to the work that they do and how they do it and how independent they are. Those issues will be addressed during our deliberations. Given the fact that the new organisation will have to fulfil the duties of the existing organisation, including Lord Patel’s, I would envisage that that would include the regularity of visits in the cases that he was concerned about.
The new commission will have the power to issue penalty notices and suspend registration for organisations or individuals that do not comply with its requirements. As you will remember, that was an area that we questioned the three existing commissions about on Tuesday, and they gave slightly different replies to those questions. Let us concentrate for a moment on what members of the Healthcare Commission said. If I understood them correctly, they were saying that they were not asking for new powers, but that they did not want them removed from the Bill, if they were in there. They were concerned that those powers should not be used at the drop of a hat. They wanted it to be established that those powers would be used on an escalating basis and that things would not come down too heavy-handedly. Under what circumstances would you expect the commission to use the new powers available to it?
Ben Bradshaw: I would expect the new commission to use its judgment and to take advantage of the new sliding scale of powers, which I think were probably more warmly welcomed by the other two organisations than by the Healthcare Commission, which feels that it already has adequate powers. You are right, Mr. Burden, to say that, when questioned, Anna Walker said that she did not want those powers to be taken out—I suspect because there is a belief that the new range of powers is not only about how the commission will use them, but the galvanising and deterrent effect that the existence of those powers will have on provider organisations. I do not think that we should lose sight of that issue, which was not really raised on Tuesday. We should leave that to the judgment of the new commission. I do not think that we should lay down in the legislation under what circumstances the commission should issue a penalty notice or suspend a licence. That will be for the commission itself to decide, in a proportionate but robust way.
On the specific issue of health care-associated infections, which came up on Tuesday, how would you expect the existence of those new powers to allow the commission to intervene more effectively on that area?
Ben Bradshaw: This is where I slightly disagreed with what Anna Walker said on Tuesday, because I think that the new powers will enable the new commission to be more flexible in its interventions in relation to health care-acquired infections and to intervene more quickly. The increase of the maximum fine to £50,000, potentially—that is for just one breach of a regulation and there could be multiple £50,000s in a very serious case—is an extra tool in its armoury. One should not lose sight of the damage to an organisation’s reputation that could be caused if it was fined in that way. The Healthcare Commission might say that it has enough powers at the moment, but the flipside of giving it these new powers is the motivational and deterrent effects on health care organisations to ensure that they improve their performance.
Ben Bradshaw: I entirely agree with that. In fact, that is one of the areas that we have been working on closely with the Healthcare Commission over recent months. One of the reasons why I was so disappointed with the tone and content of Sir Ian’s written evidence was that we have moved on that issue. The Healthcare Commission was very much concerned that its powers should not be limited to providers, given that 80 per cent. of the taxpayers’ money that is now spent on the health service is being spent through primary care trusts, which are the main commissioners. I entirely agree with that. We are confident that the Bill makes clear that the commission’s role extends to commissioning as well as provision.
Why do you think it has changed its mind? You are obviously surprised that it is coming up with different things now from what you have heard privately. What do you think has changed its mind?
Ben Bradshaw: I do not really think that that is for me to answer. We could speculate. It might be to do with the fact that this was the chance for its last hurrah—it has membership organisations and structures, it wants to be seen to be defending its existing regulatory organisations and nobody likes to be abolished. What is interesting is that by the end of the sitting on Tuesday, two out of the three organisations had acknowledged that they supported the principle of integration. They did not start in that position. I do not know; it would be more fruitful to ask it. I am not sure that it has changed its mind. I think that it is a difference in tone and a difference between when you are in public and when you are discussing how to make the best system in the future.
My understanding was that it thinks the direction of travel is right, but that it is concerned about the detail, in particular the transitional arrangements.
Going back to health care-acquired infections, I think that the transitional period is crucial in relation to those that stop for no man. An 18-month loss of focus would not be unlikely, and I understand that some organisations are already leaking staff because of this proposed change. I would appreciate your comments on that.
Ben Bradshaw: That goes back to the answer that I gave to a previous question. It is important for us to manage the transition and support the work that the three organisations—in this case the Healthcare Commission—are doing, particularly on health care-acquired infections. The Government have recently invested a large extra sum of money in the area of health care-acquired infections, and that work will continue while we get the shadow organisation up and running. The shadow organisation will have to manage the transition carefully and take on the expertise that is already there. We will help and encourage it to do so.
Ben Bradshaw: It could be, but there is provision to take more urgent action if necessary. In clauses 26 and 27, we give the commission the power to take urgent action when it considers that necessary, but in general we think that it is right and fair for a provider or manager to have the right to challenge a proposed action. I think that we have got the balance right, and there is a safeguard that more urgent action can be taken, if it is considered necessary.
Decisions on urgent cancellation will be referred to a justice of the peace. Are you confident that the judges are qualified to assess such situations—for example, whether lives are at risk as a specific result of failure to control infection?
Giles Wilmore: Primarily, yes. Obviously the Healthcare Commission will be responsible for bringing forward sufficient evidence to justify enforcing the powers that it wishes to use. The legal process will be to check that that evidence is robust and that the process of gathering it has been fair and above board.
Clause 42 talks about the reviews that the commission will carry out with respect to health and social care organisations as “periodic”. Clause 45, I understand, gives the commission the powers to set the frequency of those reviews. Does that mean an end to the annual statutory review?
Giles Wilmore: No, it means that the annual statutory review does not necessarily have to be annual for every type of provider and that the commission will determine the most appropriate frequency. For main NHS providers such as hospitals, when we have the annual health check, it is likely that we will want the annual review of performance to continue. That is what clause 42 allows.
The new commission has the power to conduct special reviews. It is not clear how it will determine and prioritise those areas, and concern has been raised that there might not be the funding to do it. Will the net effect be that it will end up reviewing only those subjects specified by the Secretary of State in clause 45?
Ben Bradshaw: No. There is no restriction from the status quo in terms of the freedom of the new commission to conduct reviews. Clearly its remit will focus on safety and quality and we have made that quite clear throughout this process. The commission will be free to conduct the reviews that it needs to with the proviso of a one-year time lapse while the registration system is got up and running.
The Bill, of course, creates a new body, the Office of the Health Professions Adjudicator, which will take over the conduct of the practice panels of the General Medical Council. In addition to the more general question of why you think that a new and separate body is necessary, I wish to point out that the GMC will still be able to publish guidance telling the OHPA what sanctions to impose on professionals found unfit to practise, thus giving rise to the potential for confusion about who has the ultimate responsibility. Given the extensive evidence that we have already had on the subject, during which, of course, you have been present, I would be grateful if you would comment on the need for total independence—particularly considering Lady Justice Smith’s evidence that she thought that a legally qualified person ought to be the statutory chair of such panels.
Ben Bradshaw: As I am sure hon. Members are aware, that was one of the main recommendations to come out of the numerous inquiries that Dame Janet Smith carried out into the Harold Shipman murders. It is widely supported by everyone, with the exception of the British Medical Association. The original motivation was the view that the independent adjudicator should be given the genesis of this, independent of medical professional interests. More recently, people have begun to debate the exact status of the body, and I point out to the Committee—we discussed this at some length on Tuesday—that people do not suggest that the Healthcare Commission, which itself is an non-departmental public body, or the Independent Police Complaints Commission and the Human Fertilisation and Embryology Authority, which are other NDPBs, are not independent of the Government. I also noted from the questioning on Tuesday that although Dame Janet expressed some sympathy with the concerns of the GMC on its exact status and distance from Government, neither she, the GMC, nor any other witnesses had a clear idea of what alternative status they would recommend for it.
On the issue of the legal qualification of the chair, if there is wide concern in the Committee about that, we are prepared to look at it. However, it is important to bear in mind that the GMC was a bit iffy about that issue because its view was that in some cases it is important—particularly in complex medical cases—that the chair has medical rather than legal expertise. That is why we introduced the provision of having a legal assessor and the possibility that the independent adjudicator may include a legal assessor. If there is a way out that would mean we could specify that it could have either a legal assessor or a legal chair, that might be a way to satisfy the concerns of both Dame Janet and members of this Committee. We are certainly happy to go away and think a bit further about that.
Can you explain why it is necessary to change the standard of proof for establishing whether a doctor or nurse is unfit to practise from the criminal to the civil standard? Were you at all concerned by the robust views put forward by the BMA on Tuesday that such a change might mean that doctors would act more defensively in future and that that could cause detriment to patients?
Ben Bradshaw: I am afraid that I was not surprised by the evidence given by the BMA on Tuesday. The BMA seems to want the Committee to reject every single recommendation that Dame Janet has made after looking into the issue for four long years. The reason why we are doing this is because, first, it was one of the central parts of Dame Janet’s report and, secondly, because all but two or three other health care professions already use the civil standard, and the others are quite willingly and happily moving towards the civil standard. They, unlike the BMA, have recognised that it is sensible to restore public confidence in the process. I do not accept that it will lead to doctors being too careful; I thought the arguing was slightly bizarre from the BMA there. Doctors should be careful, and one problem with the existing system is that you have two extremes. Because of the criminal standard, there is often reluctance to make a ruling when it is a bit borderline; whereas the civil standard will allow a whole range of sanctions, from serious sanctions to retraining or help.
Doctors should feel much more relaxed about the civil standard being used than they do about the status quo, where there is a danger that some mistreatments or mistakes go unaddressed, because you either do nothing, or something incredibly serious and damaging to the long-term career of the doctor.
So where does that leave you on the argument that there should be a sliding scale? If the potential is that the doctor’s future career is at stake, should you have to have the criminal standard? Does that argument impress you at all?
Do you expect to find more doctors and nurses being found unfit to practise as a result of the change? What monitoring systems will there be in practice?
Nick Clarke: Because of the discussion that we have just heard about the higher level, I think that the standards of proof will be virtually identical. Therefore, it is unlikely that it will lead to more doctors being found unfit to practice, because we are talking there about the higher level. On the monitoring, we have already asked the Council for Healthcare Regulatory Excellence to advise on the processes for implementing the change, and for making sure that people have adequate training—all those sort of areas. We will also continue to monitor the implementation of the change.
Thank you, Mr. Clarke. You have just brought me nicely on to what I wanted to ask the Minister about. Responsible officers are, as I understand it, a crucial part of this, in that they allow local resolution and intervention to stop the process, as was said, from getting so far down the line. Who do you envisage taking on that role of responsible officer?
Ben Bradshaw: We are not making a specific ruling as to who it should be, just as to what qualifications the person should have. We think that responsible officers must be senior doctors with a current GMC registration. There was much discussion on Tuesday as to whether it should be a medical director, and that would be perfectly appropriate. In fact, a lot of the good medical directors are, in practice, already doing this job on the ground. Yet we are not saying that it has to be a medical director.
You feel, then, that you are giving sufficient additional resources: but what about training? The wording of the question on our briefing papers is quite interesting. It says:
“All healthcare providers will have to designate a ‘responsible officer’”.
Certainly, one concern expressed by some doctors is that that is what you have to do—designate a responsible officer, and their job is done. The training of medical directors who may have no particular expertise in the field is a crucial part of that being effective.
Jonathan Stopes-Roe: First, it is not exactly the case that clause 119 only provides for serious and imminent threats. The regulation-making power in new section 45C in clause 119 allows the Secretary of State—or, obviously, Welsh Ministers—to make
“provision for the purpose of preventing, protecting against, controlling or providing a public health response to the incidence or spread of infection or contamination”.
That covers a far wider range of situations than those that are “serious and imminent”. It is worth explaining that we intend to use the regulation-making power to make regulations that will enable quite routine actions to protect public health, as well as responding to threats that may or may not be serious and imminent. For example, we intend to use the powers in new section 45C to impose standing duties on registered medical practitioners to notify cases of specified infectious diseases, exactly paralleling the system that we have at the moment, though working rather more effectively. That requirement to report is certainly nothing to do with a serious and imminent threat to public health.
In addition, clause 119 of course sets up the arrangements whereby a local authority can apply to a justice of the peace for an order to place requirements or restrictions on an individual—or indeed on things or premises—if they may be infected or contaminated, could pose a significant threat to human health, and are at risk of infecting others.
It is interesting in the evidence that the HPA was 100 per cent. happy with this and the Local Government Association was very unhappy about it, and one can easily jump to the conclusion that it, like many organisations, just sees this as a loss of power. What is also interesting is that currently, local authorities and directors of public health have a close relationship in terms of informal advice and all the rest of it. Do you see local directors of public health having that same relationship with JPs?
Ben Bradshaw: Yes. I am not sure that the Local Government Association was wholly against it, I think that it had a particular issue with the role of JPs vis-Ã -vis their own traditional role. We may come on to talk about that, but I think it was based on a slight misunderstanding of the law. The point made by one of the local government witnesses about the Litvinenko case—that under our proposals, it would mean that we would have to make 40-plus applications—is not the case. It actually makes it much easier because a single application would take in all those premises. What was interesting about the Litvinenko case was that the local authorities did not have the powers to do what they needed to do. It was based on a slight misunderstanding and, on the part of the LGA, a misunderstanding about the availability and speed of action of JPs. The HPA was right in that case. It welcomes such a move, because in its current experience, getting decisions made by JPs tends to be quicker than getting decisions made by local authorities.
What you said highlights the absolute need for clarity. Such a series of events is rare. The LGA’s misunderstanding of the existing situation in itself gives rise to considerable cause for concern, because when such issues come up, they do so suddenly. Absolute clarity about the role, and how advice will flow among JPs, local authorities and directors of public health, would be crucial.
Can the Minister look at how the legislation will fit with existing powers that are vested in the Department for Environment, Food and Rural Affairs, with which he will be familiar in terms of a large-scale contamination of the food supply that could be injurious to human health? There are already powers in another Ministry. Is what is being introduced under the Bill compatible with existing legislation? I am not talking about withdrawing a batch of something that has come out of a factory, but bigger things such as large-scale contamination of milk supply or even as the result of terrorist activity.
In the drafting of the Bill, has the compatibility with other existing powers, especially in respect of the Department for Environment, Food and Rural Affairs’ powers, been looked at?
Thank you, Mr. Conway. Minister, it might be helpful if you state your understanding of the specific aims and purposes of the grant. What do you anticipate will be the benefits? What specific measures will you be using to monitor progress to achieve those anticipated benefits?
Ben Bradshaw: The measure is aimed at helping pregnant women who, as we heard this morning, face particular stresses and pressures during pregnancy. It reflects the desire both to address the serious problems of underweight babies in this country—although a witness said earlier that help early on in pregnancy would make more of a difference in that regard, she acknowledged that help later on would make some general health improvements in respect of women and the unborn child— and the still very stark inequalities in health of both women and children. It has a multiple purpose. It is a model that a number of other EU countries have followed. I am pleased that it has been warmly welcomed by organisations that have concern for the welfare and health of children and pregnant women.
Following on from that, I wish to raise the issue of how the money will be spent. As you are aware, that is a matter of concern. Did you consider a form of voucher system? If so, why did you reject it in favour of this proposal? Did you consider extending the healthy start programme, which I believe is successful and is very much targeted on lower-income families by delivering something that they can spend specifically on nutrition?
Ben Bradshaw: Yes. We considered all those things. I am pleased that you have drawn attention to the healthy start scheme, because that is not the only state help that is available to pregnant women. There is a healthy grant scheme, as well as the Sure Start scheme that is worth £500. We did consider that scheme, but we wanted in this case something that was universal for the reasons that our witness from the National Childbirth Trust gave this morning.
A universal grant will benefit all women and, given the existence of specific, targeted grants that are based on a means test, the Government judged that there was merit in giving a grant to all women. On how they spend it, as I said and as our witness acknowledged, there is clear evidence from both this and other countries that less well-off people who experience an increase in their income—women in particular—spend a higher proportion of the extra income on their children’s, husband’s or partner’s welfare and, lastly, on themselves. That, I am afraid to say, is contrary to the Daily Mail myth that they blow it on booze, fags, bingo or plasma screen televisions.
Poor women spend a large proportion of their income on food, so is there a danger that, because the benefit is universal, richer people will spend the money on an upgrade to a super-duper baby buggy, a plasma screen television or whatever?
Also, I want to tie you down on this matter. Going back to the question asked by the hon. Member for Preseli Pembrokeshire, if, as the Government have said, the measure is about pregnant women’s and children’s health, well-being and nutrition—particularly those disadvantaged people who do not have those things—is it the best way of delivering those things?
Ben Bradshaw: Yes, and I was going to on to say—this has not been mentioned—that the impression is being given that there is no conditionality attached to the grant. There is conditionality attached to the grant—that the pregnant woman seeks professional health and nutritional advice at the time of receiving it.
Staying on the health in pregnancy grant, I am sure that you are aware that the grant will not be received until the 29th week of a pregnancy. You will be aware, too, that I have tabled a raft of parliamentary questions asking for the evidence that lies behind the initiative to bring forward the health in pregnancy grant. It would be helpful if I quote the Prime Minister’s original assertion:
“I have received powerful representations that in the last months of pregnancy, when nutrition is most important, and in the first weeks after birth, the extra costs borne by parents could be better recognised if we did more to help through the universal benefit—child benefit—which is paid to all. Maternity grants are available to low-income mothers from the 29th week of pregnancy. Help should be available to all mothers expecting a child, so child benefit will be paid on that basis to every mother—additional child benefit that now recognises the important role, at this critical moment, that child benefit can play.”—[Official Report, 6 December 2006; Vol. 454, c. 308.]
When are you going to bring forward the evidence that supports that statement and the terms of the health in pregnancy grant that we will consider in the next few days? There is an absence of evidence.
Ben Bradshaw: The reason why we are doing that is to link the grant to the maternal health advice that women will receive at that stage of their pregnancy. There is another issue that may or may not have informed the decision of other EU countries that award similar grants to deliver them at the same time—I believe that Mr. Crabb raised it on Second Reading—namely, that the grants will be made in the period after which there are few, if any, miscarriages or abortions, so we will not be making grants to women who subsequently, for whatever reason, lose their baby. We can have a semantic argument on the matter. In a way, we could call the measure “Child Benefit in Pregnancy”, but we are calling it something else.
Can we actually expect to see the evidence? There is a discrepancy between the origination of the thought, which suggested that the grant would be made in the last weeks or months of pregnancy, and the earlier time that we now hear about and, indeed, the idea of its being paid pre-conception.
Ben Bradshaw: I think we would all acknowledge that the evidence suggests that the nutritional benefits, specifically to the unborn child, are better earlier on in pregnancy. But for the reasons I have already outlined—the other help that is available for women earlier on in pregnancy; the fact that we want to tie this to specific health advice from the 25th week of pregnancy; the general pressures that women, particularly less well-off pregnant women, are under; and the pressures immediately before and after birth, to which the Prime Minister referred—on balance, we have decided that this is the most sensible time to give the grant, as have the other countries that have introduced similar measures, as I said.
I urge that, if possible, we see some evidence. I accept that you have effectively given evidence by virtue of this means, but to see any other evidence would be extraordinarily helpful. While on this particular point, I note in the explanatory notes, paragraph 32, that it says:
“In the Pre-Budget Report 2006, the Chancellor of the Exchequer announced that additional financial support would be made available to all women in the last months of pregnancy in line with the principle of progressive universalism, delivering support for all pregnant women and more help for those who need it the most.”
I was wondering what your interpretation of “progressive universalism” is.
I think “sniffy” is harsh. The question is whether it could be better spent somewhere else. That is what we were hearing from the NCT. You have acknowledged the fact that pre-conceptual nutrition is more important than nutrition later on. You are linking this to a point at which women get advice on nutrition. Well, give them advice on nutrition at an earlier stage and link it to that. The point is that the greatest benefits are delivered in the pre-conceptual phase; if we want to improve the health of young women, do it differently.
Ben Bradshaw: I think that you are seeing this grant in too narrow terms, Mrs. Milton. This is about a health in pregnancy grant—it is not solely about nutrition. The mother may choose, for example, if she has a perfectly good diet, to spend the money on exercise, which is also important in terms of her and her unborn baby’s health. I have said that there is already considerable help out there for women earlier on in pregnancy and, for the reasons I have already given, we have decided that this is the most sensible stage of pregnancy to give the grant.
Could you clarify? There is talk about health advice but it is not clear what form that will take or who will deliver it. In theory, it could just be a leaflet from a health trainer. How is it going to work?
Jonathan Athow: The intention with the grant is that the pregnant woman will need to have seen a health professional and to have got advice on all aspects of health, including nutrition, in order to receive the payment. We are trying very much to work with health professionals. We have had some very constructive conversations.
Jonathan Athow: Specifically, we have had some very helpful discussions with the Royal College of Midwives, who have been very welcoming of the proposal. We have been looking at how we can help them and use them as a way of helping to promote awareness of the grant, but also we want to minimise the burdens on health professionals. We do not want them to see this as an extra bit of form-filling that they have to do. We are working very closely to try to help them do that job. For some women—a very small proportion of women who do not seek regular contact with the health professionals—it may actually provide an incentive for them to make contact with a midwife and therefore to get access to the grant. Midwives are a group we are talking with, trying to use them as a primary way of delivering the grant.
You have clearly never had an antenatal appointment. They are generally 10 minutes long. Other checks have to be done. You cannot give that sort of advice in two or three minutes. Antenatal classes are being cut around the country. I think that this needs to be probed at a later stage as to how this is going to be delivered.
Sandra, I have to cut you off and I cannot ask the witness to respond because we have run out of time. May I thank the Minister and his team for giving evidence? He can re-join the Committee. Before I close the Committee formally, may I just remind everyone that this afternoon the meeting will be in Committee Room 9?